DIVISION OF GRADUATE MEDICAL SCIENCES

PRACTICUM APPROVAL FORM

Please submit this form to hpeinfo@bu.edu

STUDENT INFORMATION

Name

Title

Affiliation

Address

Phone Email

BU ID

YEAR IN HSE PROGRAM

☐ 1 year ☐ 2 Year ☐ 3 Year ☐ more than 3 years

INTENDED PROGRAM COMPLETION DATE

Month, Year

PROGRAM START DATE

Month, Year

PRACTICUM INFORMATION

Estimated practicum start date: Estimated practicum work hours per week:

How did you choose your Practicum Site?

PRACTICUM MENTOR

Last Name First Name Degree (MD, PhD)

Academic Affiliation and Title

Phone Email

PRACTICUM TITLE (DRAFT)

DETAILED DESCRIPTION OF PRACTICUM (include # of hours, location, and goals)

APPROVAL BY COURSE DIRECTOR (or Jeff Markuns jmarkuns@bu.edu)